Code Strep Throat Encounters With Confidence
Understanding when to code symptoms and cause codes is key. Sore throat complaints are common in every pediatric practice, especially as cold and flu season approaches. Because symptoms often overlap or mimic other illnesses, providers frequently rely on diagnostic testing to determine their cause and guide their treatment decisions. For coders, accurately reporting these encounters means understanding how test results, documented diagnoses, and associated services affect coding selection. Keep reading to learn which diagnosis and procedure codes belong on your strep throat claims. See How Potential Strep Visits Are Handled After evaluating the child, the provider will often perform a rapid strep test, such as: These tests help to determine whether a streptococcal infection is present. If the rapid test is negative but clinical suspicion remains high, the provider may order follow-up testing, such as: You’ll then report the appropriate evaluation and management (E/M) service code for the visit from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) set. You’ll also append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) when the E/M service is separately identifiable from the testing performed. If the provider does not establish a definitive diagnosis by the conclusion of the encounter, you’ll assign R07.0 (Pain in throat) to capture the child’s chief complaint. Choose a Cause Code Aside from streptococcal pharyngitis and tonsillitis, the specific organism responsible for a child’s sore throat is often left unidentified during the initial visit. Once the test results are available and the physician determines the cause of the infection, however, you can report a more specific diagnosis code from the many options available. There are a variety of illnesses that could be causing your patient’s sore throat, including the following: If testing is negative for strep, the provider must identify the organism causing the illness before assigning the most accurate diagnosis code. Depending on the physician’s findings, coders may report J02.8 (Acute pharyngitis due to other specified organisms) or J37.0 (Chronic laryngitis). Keep in mind that when you use these codes, you should identify the infectious agent with an additional code from the Bacterial and viral infectious agents (B95-B97) category in ICD-10-CM. If a patient’s strep test leads to a positive result, this normally means reporting J02.0 (Streptococcal pharyngitis). However, ICD-10-CM differentiates between streptococcal pharyngitis, laryngitis, and tonsillitis, so the code selection should reflect the practitioner’s documented diagnosis. For patients diagnosed with acute laryngitis, you’ll report J04.0 (Acute laryngitis), along with a code to identify the infectious agent from bacterial and viral infectious agents from one of the groups listed below: Remember: Always code to the appropriate number of characters when applying codes from sections B95.- through B97.-. When influenza is also present, assign the appropriate influenza code, such as J09.X2 (Influenza due to identified novel influenza A virus with other respiratory manifestations) or J10.1 (Influenza due to other identified influenza virus with other respiratory manifestations), based on the type of influenza documented. Test Your Skills With This Coding Example Dr. Taylor saw a 7-year-old established patient who had a sore throat and fever for the past two days. The fever has been as high as 102.3 degrees Fahrenheit. The patient also reports experiencing difficulty swallowing and has had a lack of appetite since the sore throat began. The patient is in mild distress but is alert and oriented. Physical examination shows a reddened throat with white patches on the tonsils. No rash is noted, and the cervical lymph nodes are without swelling or tenderness. The rest of the examination proceeds as normal. The symptoms and physical examination are consistent with strep throat. A rapid strep test is performed in the office and the result is positive. The provider prescribed a 10-day course of amoxicillin and advised the patient’s guardian to ensure the child completes the full course of antibiotics, even if symptoms improve before medication is finished. The provider also advised the guardian to have the child rest as much as possible, stay hydrated, and use over-the-counter pain relievers as needed for pain. The patient is instructed to return for follow-up in two weeks, or earlier if symptoms worsen or fail to improve within 48 hours of beginning antibiotic therapy. To code this visit, you’ll begin with choosing the E/M code. Because the patient is established, 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) is appropriate for the office visit portion. For the rapid strep test, you’ll use 87880 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A). The appropriate ICD-10-CM code is J02.0 (Streptococcal pharyngitis), which is the medical term for strep throat. Make note: Do not code J02.0 without lab confirmation. If the cause of the condition is unknown, you’ll instead code J02.9 (Acute pharyngitis, unspecified). Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
